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Current Patient
(718) 230-5046
New Patient
(929) 493-3866
Child Medical History
Child Medical History
Please fill in the form below or
click here
to download pdf version to fill and forward to us
Child Medical History
Patient/Child Information
First Name
First
Last Name
Last
Gender
Male
Female
Non-binary/third gender
Prefer to self describe
Prefer not to say
Dentist's Full Name
Email
Referred By
Birth Date
MM slash DD slash YYYY
Any other siblings seen by us
Age
How did you hear about us?
Invisalign Website
Google/Internet
Home Address
Street Address
Other
Parent Information
Parent 1
First Name
First
Last Name
Last
Social Security #
Birthday
MM slash DD slash YYYY
Home Address
Street Address
Home Phone #
Cell Phone #
Work Phone #
Relationship to Patient
Parent 2
First Name
First
Last Name
Last
Social Security #
Birthday
MM slash DD slash YYYY
Home Address
Street Address
Home Phone #
Cell Phone #
Work Phone #
Relationship to Patient
Patient's Medical History
Is patient in good health?
Yes
No
Any major illness?
Yes
No
Does patient have tendency to:
Colds
Yes
No
Sore Throats
Yes
No
Ear Infections
Yes
No
Has patient been under the care of a physician for any illness in the last 12 months?
Yes
No
Please select “Yes” to any illness or disability for which the patient is undergoing treatment:
Diabetes
Yes
No
Anemia
Yes
No
Epilepsy
Yes
No
Nervous Disorders
Yes
No
Asthma
Yes
No
Endocrine Problems
Yes
No
Tuberculosis
Yes
No
Heart Trouble
Yes
No
Prolonged Bleeding
Yes
No
Rheumatic Fever
Yes
No
Fainting/Dizziness
Yes
No
Bone Disorders
Yes
No
Any other illness we should be aware of
Have tonsils and adenoids been removed?
Yes
No
At What Age?
List any drugs/medications now being taken, and give reason
List any allergies or drug sensitivities
Has the patient reached puberty?
Yes
No
Height
Weight
Any instruments played?
Is the patient involved in any other activities?
Patient's Dental History
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Has the patient ever sucked a thumb or finger?
Yes
No
Until what age?
Does the patient have any speech problems?
Yes
No
Is the patient a mouth breather?
Yes
No
When does patient mouth breath?
While awake
While asleep
Have you been informed of any missing permanent teeth?
Yes
No
Has either parent ever had orthodontic treatment?
Yes
No
Have you previously consulted an orthodontist?
Yes
No
Reason for consultation today?
Δ
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